Archive for December, 2022

I will go with the last response. As for as I understand, we have never quantified Atrial muscle mass properly even in normality. One may be tempted to think there is no purpose to measure it, other than academic reasons. The fact that the incidence of atrial fibrillation in mitral stenosis is not linearly correlating with LA size makes us think, LA mass (Virtual LAH) may have a say in triggering AF.

This post is meant for cardiology fellows. Maybe someone can do a study on this by measuring LA mass pre and post-PTMC, we might get an idea about regression as well. Meanwhile, we are well versed with infiltrative diseases like atria like amyloidosis that can mimic LAH. Currently, we realize fatty infiltration of LA is the common trigger for AF in varied populations.

By the way, readers are welcome to post any specific formula to measure LA mass if they come across .


A good review of LA anatomy.

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(This post is about some basics in echocardiography meant for fellows, and echocardiographers. Others can skip please ) 

This is a 27-year-old woman who was referred for routine* cardiac evaluation. What do you see?

What is the diagnosis?

This echo clip is from a woman who is 8 months pregnant. What you are seeing is perfectly physiologically and normal. On lying down there is a mechanical push of the diaphragm altering the LV shape and contraction. In the short axis, the left ventricle is contracting well, but the shape is not spherical in systole implying some desynchrony. Further, the  IVS arena is contracting vigorously, which makes, the other segments appear to be poorly contracting. (Someone could report it as a wall motion defect in antero- lateral segments inviting temporary panic)

It is worthwhile to go through this list of non-ischemic WMA and find the pregnancy at the bottom of the list.

Few more conditions, that can be added to this list

  • Though LBBB is the classical cause for WMA, we have seen even LAFB showing the bumpy motion of IVS and the anterior wall.
  • Some patients with ERS and some patients with Brugada show wall motion defects due to repolarisation heterogeneity. 
  • Regioanl pericarditis
  • Intracardiac scars. Localized fibrosis.
  • Extracardiac tumors 

iFAQ on this topic 

Is this wall motion defect in pregnancy, really an artifact or real? 

They are true artifacts in the sense, the heart is an innocent bystander in this pulsating fight between intra-thoracic vs intrabdominal pressures. A similar situation happens in ascites. 

Any other mechanism other than mechanical push?

WMA due to RV volume overload of pregnancy may also contribute. 

Does this WMA affect cardiac hemodynamics?

Logically it should, but it doesn’t. The normal heart has enormous resilience, it just ignores these subtle pushes from below and keeps working normally. Still, enormous distension of the abdomen especially in twin pregnancies, in small body habitus, can make some women breathless, or orthopenic. I am sure, one of the mechanisms could be this geo-mechanical encroachment.

Final message

Wall motion defects are not synonymous with CAD. There is an important list of non-ischemic conditions that can cause WMA. Cardiology fellows and echo technicians are encouraged to go through the above list one more time. While this knowledge can prevent false alarms, at the same time it is always wise to ask for the ECG before doing echocardiography, and not to miss the omnipotent CAD.


*DIscerned readers might wonder why a routine echo was done in a normal pregnancy. I am surprised to note there is an ongoing fad in this part of the world, to do echocardiographic screening on every pregnant mother to rule out cardiovascular disease. (A luxury even the world’s richest country can’t afford) I am told, this echo is meant to rule out peripartum cardiomyopathy for legal purposes. A spot echo at term can never be going to either predict as an event that is mainly going to happen postpartum. This newfound epidemic of anxiety among obstetricians is unwarranted. 


A well-written focused review specifically on this topic 

Yavagal ST, Baliga VB. Non-Ischemic regional wall motion abnormality. J Indian Acad Echocardiogr Cardiovasc Imaging



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Putative mechanisms 

Forget about the mechanisms. Is it really beneficial?

Very valid question. No simple answers are available. But, some truths try to emanate from this big epidemiological study by INTERHEART that found the beneficial effect of minimal amounts of alcohol with a wide geographical variation.(Mind you INTERHEART can be Interpreted totally differently if type and amount of alcohol are counted)

How much alcohol is acceptable asper ADA recommendation?

The ADA recommends no more than one alcoholic drink per day for women • no more than two drinks per day for men. One drink is defined as 12 ounces of beer • 5 ounces of wine • 1 ½ ounces of liquor.

Does this apply to the Indian population?

No, it doesn’t apply for behavioral and possibly genetic reasons.  (A. Roy, et al Impact of alcohol on coronary heart disease in Indian men, Atherosclerosis, Volume 210, Issue 2, 2010, Pages 531-535,) 

                                            One of the daily scenes In India, at an Alcohol-human Interaction site 

Final message

It is true, disciplined alcohol intake seems to do good if the person takes care of his other lifestyles and potential risk factors. The beneficial effect of moderate alcohol on lipids, and vascular endothelium is based on a weak evidence base, but still good enough to create a recommendation. These (flimsy ?) advantages of alcohol are lost if it exceeds 2 units per day. Meanwhile. let us be aware, alcohol enhances the global burden of disease by many folds and  it should never be tried as the therapeutic drug is a logical and popular opinion (Lancet 2016)

Further research question

All of us would agree, regular alcohol intake, in any amount will end up in danger for native Indians. Now, can an NRI or resident Indian, blessed with so-called western drinking discipline accrue the true benefits of moderate alcohol intake? is a  big research/common sense question.


1.Conner H, Marks V: Alcohol and diabetes: a position paper prepared by the Nutrition Subcommittee of the British Diabetic Association’s Medical Advisory Committee.  Diabet Med 2: 413–416, 1985


3.Vu KN, Ballantyne CM, Hoogeveen RC, Nambi V, Volcik KA, Boerwinkle E, et al. (2016) Causal Role of Alcohol Consumption in an Improved Lipid Profile: The Atherosclerosis Risk in Communities (ARIC) Study. PLoS ONE 11(2): e0148765. https://doi.org/10.1371/journal.pone.0148765

4.Leong DP, Smyth A, Teo ; INTERHEART Investigators. Patterns of alcohol consumption and myocardial infarction risk: observations from 52 countries in the INTERHEART case-control study. Circulation. 2014 Jul 29;130(5):390-8. 


* ELI -Evidenceless Imagination (Closely associated with class C evidence)


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